Health Reform: Private Sector & GP Role Confusion

Health Reform: Private Sector & GP Role Confusion

Dr David KL Quek

drquek@gmail.com

(President's Page, MMA News October 2010)

“Physicians must become a constructive voice in deciding how health care costs can more appropriately reflect society’s values and needs. Planning for that eventuality should begin now, but cannot be led by a single specialty organization, cannot aggravate the town/gown split in medicine… and cannot be performed in a way that violates the Hippocratic oath. However, it must be done. At the very least, a set of detailed options needs to be developed to contain costs, and physicians should lead the debate about how such options might be implemented. There is no group more trusted in society than physicians. If anyone can lead development of such a plan, it should be physicians.” ~ Robert H. Brook, Rand Corporation[1]

Health Reform Vs. Changing Social Demands & Needs

It has been said that change must be transformational, even radical, if it is to have its most paradigmatic footprint on society that the reformist or revolutionary wishes to leave behind.

Most leaders appear to love these types of change, of wanting to be seen to be bold, novel and innovative, yet impactful and perhaps most importantly, best remembered historically.

Aneurin Bevan has been immortalized as that one socially-driven politician, who had established the National Health Service (NHS) for Britain in 1948, during the socioeconomic turmoil following World War II. Half a century on, its iconic legacy has been contentiously recognised as arguably the most enduring model of health system for the modern world. Even if at times, the NHS appears archaic, and unable to meet the growing demands of contemporary society and its knowledge-savvy citizens.

But even as we continue to debate the NHS’ longevity, the new British government is bent on reforming and liberalizing its lead-shorn laggardness.[2] Command single-payer systems may work but can also become unruly and top heavy. So much so, that demands for individual choice crescendo to become a deafening clamour for better, more efficient delivery of safe and timely healthcare.

Not many ill patients are now willing to resignedly wait their turn, to queue as per economically-dictated rationing. Even if this individualistic preference is achieved at some higher premium costs! Essentially, more and more people are expecting and demanding more personalised rather than uniform factory-style care—impersonal cogs on the grinding wheels of soulless clockwork but cost-constrained efficiency is not enough.

But grappling with societal demands versus economic reality is not always easy, nor entirely logical. There is always that irrational component of wanting more individually, than what is best for the larger good of the many. This applies to healthcare more so than to other social demands or needs. We demand this as of our human right, but also wish upon that seemingly nonnegotiable luxury of timely, proficient, safe and compassionate care.

Paradoxically, no one wants to pay more than he or she needs to, and yet hankers for unfettered access to more and more medical advances. We all want new and up-to-date therapies and indulge in ephemeral dreams of erstwhile longevity or prolonged physical beauty, while at the same time we begrudge rising if unpalatable costs! Governments and policy makers are thus caught in this quagmire of finite resources, limited supply and endless demands.

Private vs. Public sector restructuring

For Malaysia, authorities have once again resurrected plans to restructure our health care system, perhaps this time far more comprehensively, drastically even, than ever before. Thus, in tandem with the slogan-heavy pronouncements of the government of Dato’ Sri Najib Razak, we are now introduced to the concept of ‘1Care for 1Malaysia’ health restructuring.[3]

We have the 1Malaysia, the GTP, the NEM, the recently heralded ETP: Economic Transformation Programmes, hence the current acronym of “1Care for 1Malaysia” for healthcare reform.

To be sure, these plans are now much grander, more re-engineered to fit the model of a marked policy shift both in terms of funding as well as structure. But, coming in the prolonged wake of our widely expanded private sector over the past 25 years, such plans to integrate public-private sectors, cause much confusion and understandably some resistance as to the final direction and form of where our health care system is heading.

Having said this, we are not Luddites who irrationally oppose change for the mere sake of it. We strongly believe there are genuine concerns that many if not most practical aspects of such a huge undertaking have not been worked out satisfactorily. That perhaps, some of these ideas might not be the best that have been articulated, and which might need exhaustive scrutiny and public feedback.

Herein lie some of the unspoken nitty-gritty ‘devils in the detail’—there’s been minimal consideration for practical particulars, but much theoretical and high-sounding huh-hahs and noises. We however, accept the contention by some officials that this is very much “work in progress”.

“Health reform is not only about health insurance companies, physicians, and pharmaceutical and device companies.

It is not only mandating health insurance for everyone… Health reform is about people. And people must become full participants and assume much greater responsibility for their actions if health benefits are to be maintained at an affordable cost.” ~ Richard H. Brook, Rand Corporation[4]

MMA believes that change should not be based on misplaced or erroneous premises. While the privatization approach is contributory and possibly instrumental in the world’s experience of skyrocketing healthcare costs, this is but one dynamic of free-market economic forces, not the one all and be all.

However, the lurking suspicion that private healthcare is the root evil of all healthcare woes is a cynical approach to the dilemma of strategic healthcare planning in the midst of escalating and apparently uncontainable costs.

The MMA wonders if the authorities and the government continue to believe in the free-market and private sector of health care in this country, or is this the start of a determined effort to gradually dismantle the private sector altogether?

This is not to say that we believe in the unbridled rise in healthcare costs to untenable levels, leading to gross inequity in access to the poorer segment of society, or to those haplessly afflicted by catastrophic illness. MMA continues to staunchly believe in and advocate for a sustainable model of universal access to healthcare for all.

It is the ‘how’ and ‘what’ of achieving this, which causes much discomfiture. What’s the final product like? How would this ultimately affect the medical profession and the public?

Thus, the transformation plans must clearly position the roles of the private vs. the public sectors despite the possible move toward a single payer system, where contract purchases of private services could still serve to improve efficiency in the delivery of health services.

1Care for 1Malaysia Health Reform

What is 1Care? “1Care is the restructured national health system that is responsive and provides choice of quality health care, ensuring universal coverage for the health care needs of the population based on the spirit of solidarity and equity,” says the MOH.

Theoretically, such a definition is fully acceptable. It is a neat slogan and concept, but just how this is to be realised is somewhat contentious, with the details being quite unclear, as of now.

More importantly, the question that needs to be asked is, why change, why now, and if so, how?

The government and the MOH has considered reform for some time now, perhaps as long as 15 years according to MOH officials, with inputs from several sources including many experts and consultants the world over as to how we can transform our health system into something even better.

One theme keeps recurring, “Is our current system of an entrenched dichotomous private-public approach sustainable?”

According to our government, this appears not. Healthcare cost is rising and shows no signs of abating as elsewhere in the world. Health care spending has been increasing and out-of-pocket (OOP) payment for health care services especially in the private sector has been mounting.

The proportion of OOP is now around 40%, which mimics the profile of a third world ‘underdeveloped’ economy. Most developed nations have only 20 to 25% OOP in their health expenditure profiles, with the government and the Social Health Insurance (SHI) partaking of around half to two-thirds of the Total Health Expenditure (THE). Unfortunately the Malaysian government contributes just 44% of the country’s total health spending, with the private sector playing catch-up to fill in the void created.

In MMA’s view, the government spends too little on our health care: the government contributes just 2.1% of the GDP to healthcare (from government tax revenue allocations) with the private sector taking up the slack of another 2.7%. Our healthcare expenditure is around 7% of all total government spending, but still accounts for only a paltry 4.8% of the total GDP.[5] WHO recommends at least 8%. Most developed economies spend some 8 to 15% of their GDP on healthcare.

We can do this better. We need greater government commitment to healthcare budgetary contribution, perhaps 4% of the GDP, in order to take leadership and encourage the private sector to emulate these more committed efforts. Together perhaps we can consider expending some 8 to 10% of our GDP for health care.

We agree that we are facing many challenges: we need to a) ensure that our services meet our patients’ needs, b) to enhance our performance to ensure higher quality of care and c) ensure that our healthcare delivery is less sporadic and more equitable, i.e. we need to overcome our limited and mismatched health care resources. However, many are asking: “If it ain’t broke, why fix it?”

A WHO consultant has actually expressed caution when discussing the need for drastic change. According to internal sources, he has recommended the following:

·       More evidence to assess if the benefits of the reform justify the costs

·       More analysis on service delivery aspects of the reform

·       Exploration of ‘partial’ reform options

·       Piloting of different components of the 1Care proposal

Interestingly, in a World Health Report 2006[6] (Working Together for Health), the WHO has found that most Malaysians surveyed had a favourable impression of our healthcare delivery i.e. 88% of patients perceived of having been treated with respect in their last encounter at a healthcare facility.

Importantly for a nation which spends just under USD500 per capita on healthcare per annum, our health statistics are quite impressive: our under-5 mortality is remarkably low, our life expectancy has also progressed remarkably well, i.e. we are above the curve of cost-efficient healthcare ourcomes, although clearly we can do much more to improve our lot!

The GP Misconception & Private-Public Integration Plans

One of the pillars of the touted transformation is the public-private integration plans of the new system, now suggested to take place over a longer spread of time, perhaps through the 10^th to 11^th Malaysia Plans i.e. 10-15 years even.

Here, the overall plan is to move towards a primary care provider-led system, with the thrust towards more promotive-preventive care and early intervention. Family medicine specialists would serve as hands-on first provider as well as gatekeeper function in a totally revamped primary care-led referral system. Payments for services would be via capitation methods and case-mix models, clearly a huge shift to the unknown.

According to our MOH officials, our current crop of GPs would have to be retrained, re-credentialed and ‘upgraded’ to be able to fit into the system, which is one particular area where MMA strongly feels is unfair and onerous. The unwilling or the ‘untrained’ GP would be relegated to a lower level of a minion worker.

For some reason, there has always been that cynical belief by the health authorities that our GPs out there have been short-shrifting our patients thus far, that they have failed to deliver an appropriate level of care to our patients all these years. This, we believe, is unjustified and unlikely to be the general truth.

This has come across starkly in some of our dialogues with the Ministry of Health (MOH). Such is the mindset and perception of our health authorities! There is that prevalent feeling that GPs are not good enough and have done too little to improve the standards of their practice, although this has not been borne out by whatever little data that we have.

This is especially ironic when you consider that all our GPs have ‘graduated’ from the public system through at least 3 and now 4 years of compulsory service.

What does this imply for the apprenticeship role of the MOH, when the housemanship years are now extended into 2 years with mandatory rotations through various disciplines, and another 2 years of medical officership? Perhaps this speaks volumes for the disordered or ‘failed’ approach in ‘training’ or utilizing our MOs that they should still be considered inadequate after 5-6 years of medical school, 3-4 years of supervised housemanship and even mandatory medical officership!

I think this is grossly unfair to our doctors, that they should be perceived this way, unless there are inherent weaknesses in the system of training and supervision… Then the fault lies elsewhere, which must be corrected! I believe no other profession undergoes such a prolonged rigorous phase of supervision and still suffers the ignominy of being considered inept!

Even the lawyers have just one year of pupillage, post-CLP! We are not talking about rocket science here (even then the astrophysicist or engineer undergoes not more than 3-4 BSc, plus 4-5 years of PhD!), but basic general and yes, even family medicine practice!

But, it may be time for MOH to institute a more systematic training module for GP-wannabes; a more structured and perhaps senior GP-attachment for hands-on approach… This may be the preferred system than simply using the newly-minted medical officers as fresh pairs of hands to cover unwanted and unpopular disciplines, e.g. emergency departments, pathology, outpatients, administration, etc.

It is true that we have a dearth of information or research data pertaining to the performance or outcomes of our GPs. The MOH decries the fact that too few GPs participate in any surveys and studies to evaluate their services, their worth and outcomes. But this does not mean that our GPs are second-rated, as believed by the MOH.

Underperformance occurs in both public and private sectors

On the other hand, we have had at least 2 reports from the MOH describing just how poorly some of our public clinics have performed especially with respect to clinical and medication errors, etc. in particular those pertaining to non-doctor based services, i.e. those carried out by medical assistants or nurses.[7]

According to a Penang study, in 2009, “medical assistants at government health clinics and government hospitals were found to be responsible for many medication errors. Of the 1,612 prescriptions generated by medical assistants in a single week, 1169 errors were noted and some were critical errors, involving the use of at least one medication categorised as Group B medicine, which only medical officers are authorised to prescribe.” [8]

To claim that several global health officials have expressed favourable opinions on our public health system, thereby implying that our government-run clinics are therefore excellent, is misleading and perhaps too self-congratulatory!

We readily accept that our infrastructure and system of primary healthcare access to most of our rural population within 5 kilometers is laudable, and has been adopted by other developing nations. But we beg to differ that these services provide the ‘best’ care that can be offered.

Consider the following mundane scenario of nearly every ‘public’ outpatient clinic, countrywide.

When it comes to chronic disease management, delivery of care is to say the least, sparse, sporadic and generally basic. There is very little continuity of care, with almost every clinic consultation (stretched to once in 4 to 6 months or longer!) being attended to by a different doctor nearly every time. Some 2 to 5 minutes seen in an overcrowded 2 to 3 patients in a shared space, cannot be the best approach—overworked medical officers furiously scribbling in self-kept medical cards, whatever little history, examination or tests, and in most instances, a rehash of the previous prescription (with little or no change), cannot truly imply good care or outcome!

Contrast this with the usual GP, who more often than not looks after families and perhaps even generations of families. The personal touch is all the more apparent in many cases, where chronic disease ailment such as hypertension, diabetes, arthritis and even some stable CVD are often looked after as best can be, with cost constraints being the usual bugbear. But GPs are adept at balancing costs with acceptable outcomes, and obviously do provide sufficient counseling to matter for the returning patient.

True, they also look after acute ailments such as fevers, cuts, falls, bruises, etc. Some even dabble in occupational health after undergoing some relevant courses. True too, that many a GP would prefer not to see the very ill or gravely injured patient due to lack of facility or support services. But such is the sagacity of good clinical practice to know one’s limits and refer judiciously.

The contention that many patients in the private sector doctor-hop and shop around is not the usual phenomenon, and probably occurs in a minority. But we do need more data to confirm or refute this and we urge our GP colleagues to participate in more studies to really address such possible misconceptions.

We also need to find out why many patients utilizing the public sector clinics revert to the GPs for either follow-up care, second opinions or reassuring care once in a while; or vice-versa—we need to document how well or how poorly some of these public-private shift of patients are doing and why.

We personally know of so ‘many’ instances of poor control of BP or blood glucose or HbA1c from government clinics that we must document the extent rather than just dwell in smirking hearsay. We urge GPs to document these carefully so that we can provide feedback of such suboptimal care to the authorities.

Similarly, the public clinics can and should also cross-document the mistakes or poor performances of the GPs or private sector out there. In the interests of patient safety, this should be the ongoing concern of every practicing physician, not to find fault but to monitor safety, so weaknesses can be identified and rectified. Until then, we believe that many of these are unfounded and based on inherent prejudices which apply both ways!

Market Forces & Private Sector Vibrancy

But perhaps the reality is simpler. MMA contends that the staggering 62% of the total Malaysian outpatient population, who rely on our GP services, cannot be an anomaly or a quirk of fate or circumstance!

Market forces, ease of care access, cost-effectiveness and reasonable outcomes, mean that most GPs must be doing something right. Of course there is information asymmetry, and that many patients may not know better, but we believe they are not stupid.

Of course, some patients do doctor-hop to find the best, most effective and most accommodating! After all, would anyone pay good money to have his/her illness badly treated, month on month? Would companies pay their panel doctors so that their employees’ health profiles deteriorate with time?

While insurance companies and third party payers complain bitterly about rising costs, would they continue to service such inept doctors if they are as bad as perceived?

Thus, we believe that the authorities have got their perceptions wrong, but we stand ready to be corrected.

The MOH must shift from their moral high ground and engage with the private sector, which play their critical part in alleviating the crush of needed services that the public sector cannot provide satisfactorily to the more discerning population. That despite their suspicion that market-driven health care is fraught with mercenary conflicts, this does not necessarily mean that the paying patients receive poor or sloppy care!

In most instances, the MMA believes that most patients (whether private or public) in Malaysia do receive a decent modicum of health care services, which are appropriate and cost-effective. But access can be improved particularly for the urban poor and the remote/rural needy.

Chronic disease management of course can be improved too, and our health indices must show better outcomes—the steady rise in non-communicable disease profiles is worrisome and may be reflective of public health malfunction due to faulty lifestyle excesses rather than therapeutic failures.

Catastrophic outcomes on the other hand can be better managed by both better promotive-preventive population-based measures, and yes, better concerted approaches to holistic chronic disease management. Of course, this implies that every doctor should actively engage in continuing professional development—we believe this is crucial for modern practice and professionalism.

We must find a middle path towards realising a more acceptable approach to reform our healthcare system, but we all need more data, research as well as greater stakeholder feedback and buy-in.

Misidentifying the private sector as a healthcare cost adversary would be off-target, and would only serve to deviate from the genuine problems associated with modern healthcare!

Also, by adhering to persistent and mistaken precepts, we may embark on a restructuring programme, which may meet with stout resistance and uncertain outcomes from both the medical profession and ultimately the more knowledgeable and empowered public.

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[1] Robert H. Brook, MD PhD, Rand Corporation. What If Physicians Actually Had to Control Medical Costs? JAMA 2010: 304(13):1489-90

[2] Department of Health, UK. Equity and Excellence: Liberalising the NHS. London, DH, July 2010

[3] Dato’ Dr Maimunah bt A Hamid, Deputy Director General of Health (Research and Technical Support). 1Care for 1Malaysia:
Restructuring The Malaysian Health System. Presented at the 10^th Malaysia Health Plan Conference on 2^nd  February 2010

[4] Richard H. Brook, MD, PhD, Rand Corporation. Rights and Responsibilities in Health Care – Striking a Balance. JAMA 2010;303(22): 2289-90

[5] Ministry of Finance, Government of Malaysia. National Budget 2010

[6] World Health Report 2006 (Working Together for Health), Geneva, 2006

[7] Khoo EM, et al. Medical Errors in MOH Primary Care clinics. Research Highlight IPSK/H0/602/003/002(26)/2 of 2008/e2. Letter of intent for improving Patient Safety: Primary Care. MOH/S/IPSK/05.08(RR)

[8] Dr Jayabalan T and others, The Star, 07 January 2010, pg N45